Volume 105, Issue 5 (July 2006)

Editorials

Not only is it an honor to be named editor of the Wisconsin Medical Journal, it is particularly challenging to follow Tom Meyer, MD, whose distinguished record as a clinician, educator, and medical editor has raised the Wisconsin Medical Journal to a new level of excellence.

Commentaries

Wisconsin children are not immune from the epidemic of obesity. Childhood obesity continues to increase in the United States at epidemic proportions. A recent report from the National Health and Nutrition Examination Survey (NHANES) reported that the prevalence of overweight in children and adolescents in the US population increased significantly in the 6-year period of 1999-2004, from 13.0% to 17.1%. The news was worse for male children and adolescents, and those children who were non-white, with rates of overweight greater than 18% in those population subgroups. More than a third of all population sub-groups were at-risk of overweight or were overweight.

The term “metabolic syndrome” has recently become en vogue. But is the definition realistic, or helpful? This paper looks at the current definitions of metabolic syndrome and the bearing it has on clinicians both now and in the future.

Original Research

Objective: The American Academy of Pediatrics has issued a primary pediatric obesity prevention policy statement. Its focus is directed toward the health supervision visit. We used qualitative research to determine physicians’ approaches toward obesity prevention within this visit.

Results: The pediatrician’s role in obesity prevention is education and detection. Pediatricians provide information on proper nutrition, physical activity, media time, and parenting skills. These pediatricians routinely discuss (1) junk food, (2) balanced diets, (3) nutritional requirements, and (4) parental techniques to promote healthy approaches to food. They discuss methods to increase physical activity and routinely recommend limitations to media time. However, only a third use body mass index (BMI) charts during their health supervision appointments and many are uncertain how to tailor guidance to children with obesity risk factors.

Conclusions: Pediatricians follow many of the obesity prevention guidelines. Further evidence is needed to understand the effectiveness of their education and detection methods. Potential areas for improvement include use of BMI charts and counseling with specific obesity prevention in mind.

Statins frequently do not control all of the lipid abnormalities found in patients with the metabolic sydrome. Pioglitizone (PIO), an insulin sensitizing agent, has been shown to have favorable lipid effects in diabetic patients. Little information is available regarding the effect of combined statin and PIO therapy in non-diabetic patients with the metabolic syndrome. We report our experience of adding PIO to statin therapy in non-diabetic patients with the metabolic syndrome. Pioglitazone was administered to 24 non-diabetic patients in our lipid clinic who were already on a statin yet continued to have significant lipid abnormalities. All patients had characteristic lipid abnormalities and clinical features of the metabolic syndrome. The treatment period was 59±29 (range 7-123) weeks. Lipid profiles, fasting glucose, and alanine aminotransferase were assessed before and at least 6 weeks after pioglitazone was added to statin. Triglyceride levels decreased from 307±295mg/dL to 173±129mg/dL (P=0.003), non-high-density lipoprotein cholesterol (non-HDL) decreased from 151±53mg/dL to 130±49mg/dL, (P=0.003), and high-density lipoprotein cholesterol (HDL) levels increased from 42±11mg/dL to 45±12mg/dL, (P=0.039). The addition of PIO to statin in non-diabetic patients with metabolic sydrome produced significant additional benefits in the lipid profile over statin monotherapy. Favorable effects were seen in triglycerides, HDL, and non-HDL levels. Study limitations include: this is a small non-blinded observational study in which patients served as their own controls. The duration of combination therapy and type of statin employed were variable.

Objectives: In 2000, the Wisconsin Legislature allocated $20.8 million annually to establish a comprehensive tobacco control program. The purpose of this study was to evaluate the impact of Wisconsin’s tobacco control program on reducing cigarette consumption during its first 2 years of operation.

Methods: Per capita cigarette sales were used to estimate cigarette consumption. Trends in cigarette consumption in Wisconsin between 2001 and 2003 were compared with trends in the United States as a whole, with groups of states, and with Wisconsin’s peer state group.

Results: Cigarette consumption in Wisconsin declined 9.2% from 2001 to 2003. In the same time period cigarette consumption in the United States declined only 3.8%. Wisconsin also demonstrated a greater percent decline in its cigarette consumption rate than did 3 of the 4 state groups. Finally, compared to its peer state group Wisconsin performed better between 2001 and 2003, with a decline of 9.2% compared to only a 4.2% reduction in its peer state group.

Summary: Wisconsin has shown progress in reducing cigarette consumption during the first 2 years of its tobacco control program. Greater declines in Wisconsin compared to the United States, most state groups and its own peer state group suggest early effectiveness of Wisconsin’s tobacco control program. Wisconsin will require continued implementation of evidence-based policy initiatives and aggressive tobacco control activities in order to maintain its progress toward decreasing the public health burden of tobacco.

Introduction: Risk factors for cardiovascular disease and diabetes acquired in childhood commonly persist in later life and are particularly strong predictors of subclinical atherosclerosis in young adults. A rising tide of obesity and other lifestyle-related risk factors threatens to negate much of the success achieved in the prevention and treatment of these diseases. The SCHOOL project (School Children Have Leading Risk Factors for Cardiovascular Disease and Diabetes), was designed to measure the prevalence and magnitude of known risk factors in school-age children in Wausau, Wis.

Methods: Demographic data, anthropomorphic measures, family health history, diet and activity indices, and numerous laboratory measures were collected from a representative sample of students in grades 2, 5, 8, and 11.

Results: Clinically important disturbances of lipid metabolism were very common, even in the youngest participants. Of the children studied, 39% had at least 1 lipid abnormality and 22% had 2 or more. Abnormal blood pressure, overweight, and cigarette smoking were present in 29%, 16%, and 11% respectively. While elevated fasting glucose levels were uncommon, insulin resistance was noted in 25% of the sampled population and nearly 50% of sampled children with a body mass index greater than the 85th percentile in this survey. The number of children with multiple risk factors rose dramatically with age. By 11th grade, 38% of those surveyed had 2 or more risk factors and 23% had 3 or more.

Conclusions: Using conservative definitions, significant abnormalities of lipid metabolism and other risk factors for cardiovascular disease and diabetes were common in our children. Risk profiles in older adolescents were worse than in the younger students and similar to what would be expected for adults with known coronary heart disease. In our community there is a growing consensus that we must take advantage of the multiple opportunities that exist to favorably alter the lifestyle patterns that put our children at risk.

Review Articles

Emergency contraception is used to prevent pregnancy in the event of unprotected sexual intercourse. The most common methods of emergency contraception are combination and progestin-only oral contraceptive pills. They are effective, safe, and have few side effects. Most physicians are aware of emergency contraception, yet it is not widely prescribed or used. The American Medical Association and the American College of Obstetricians and Gynecologists recommend providing information and access to emergency contraceptive pills at routine gynecologic visits. Evidence has shown that women provided with advance supplies of emergency contraceptive pills were more likely to use them. There is no evidence of increased sexual risk-taking behavior or reduction in use of regular birth control methods. It is estimated that with wider use of emergency contraceptive, nearly half of unplanned pregnancies and abortions could be prevented. Access and knowledge of emergency contraception are the biggest barriers to use. Many emergency departments in Wisconsin do not prescribe emergency contraception, making access for women in rural areas difficult. By increasing use of emergency contraceptive pills by improving access and improving patient knowledge, unplanned pregnancies and abortions may be reduced.

Case Reports

A case of sacral chordoma clinically simulating pilonidal ‘cyst’ in a 47-year-old male is presented. The clinical presentation with radiographic and histologic features of this entity with post-treatment clinical follow up is presented with a review of the literature.

Introduction: While allergic reactions to poultry products in the form of feathers and eggs are common, allergic reactions to chicken meat are rare. Despite the popularity of chicken in today’s healthy diet, severe reactions after ingesting chicken meat are rarely described. This report describes a patient who developed chicken meat anaphylaxis without experiencing allergy to eggs or feathers.

Methods: A carefully obtained history from a 41-year-old male suggested chicken meat as the cause of his symptoms. He developed abdominal cramping, generalized urticaria, and chest tightness after ingestion of chicken meat. Percutaneous allergy skin testing with commercial chicken and turkey extract and freshly cooked chicken utilizing the prick-prick test was performed.

Results: Skin testing was positive with all extracts of chicken and turkey in the patient, and negative in 4 healthy adult controls. Skin tests with feather and egg extract were negative.

Conclusion: This is the third report of severe allergy to chicken meat in the absence of egg allergy. Physicians should be aware of the presence of chicken allergy without concomitant feather or egg allergy, particularly in adults.

On May 25, 2006, the Centers for Medicare and Medicaid Services (CMS) issued a press release reminding covered health care professionals that the deadline for obtaining National Provider Identifiers (NPI) is quickly approaching. In the press release, CMS strongly urged covered health care professionals to take action now to have their NPIs well in advance of the deadline. HIPAA-covered health care professionals, health plans, and health clearinghouses must use the NPI in standard transactions—specified by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)—beginning May 23, 2007. Small health plans have until May 23, 2008 to comply.

It’s human nature to root for your home team, and many investors follow suit with their portfolios. Home country bias is common for US investors. However, developed international markets (MSCI EAFE Index) have outpaced domestic (S&P 500) over each of the last 4 calendar years. This leads the US “Homer” investor to wonder if they should consider investing outside the United States.

Your Profession

Heart disease, stroke, diabetes—these are the grim promises of metabolic syndrome, an epidemic growing in step with waistlines, cholesterol levels, and blood pressures in the United States, affecting an estimated quarter of the US adult population. Since metabolic syndrome comprises a constellation of health risks, we must hunt in multiple areas for new diagnostic and therapeutic tools to increase our odds of successfully combating this ubiquitous problem. The insights gained by Medical College of Wisconsin researchers in recent months give me confidence that our multifaceted approach will bear fruit.

The recurrent controversies surrounding Guantanamo Bay bring to mind the time I spent there a decade ago as a military physician. As an Air Force infectious disease specialist, I was deployed to the Guantanamo Bay naval base as part of the military’s response to the Cuban and Haitian refugee crisis in 1994-1995. During my stint on that desert island I saw compassion, hope, and frustration, and the first detentions of foreign citizens that would get us into trouble later.

Letter to the Editor

The Eau Claire County Department on Aging & Resource Center has been developing a patient education project we would like to share with physicians around the state. The program is designed to provide education to the largest segment (58.8%) of the approximately 42.7 million Americans affected by arthritis and has been well accepted in the senior apartment complexes in Eau Claire County. The program consists of: • a PowerPoint presentation • an adaptive equipment demonstration • a fall prevention component • a nutrition component